Provider Demographics
NPI:1013196799
Name:METROLINA ANESTHESIA LLC
Entity Type:Organization
Organization Name:METROLINA ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:C
Authorized Official - Last Name:DEATLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:704-604-8206
Mailing Address - Street 1:8000 CORPORATE CENTER DR
Mailing Address - Street 2:SUITE 208
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-4464
Mailing Address - Country:US
Mailing Address - Phone:704-540-4350
Mailing Address - Fax:888-422-9661
Practice Address - Street 1:800 W MEETING ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-2202
Practice Address - Country:US
Practice Address - Phone:803-286-1214
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDH2057OtherRR MEDICARE
SC8899Medicare PIN
SCGP4826Medicare PIN
SCDH2057OtherRR MEDICARE